Running head: EDUCATION AND COMPASSION FATIGUE 1

Transcription

1 Running head: EDUCATION AND COMPASSION FATIGUE 1 Utilizing Education to Combat Compassion Fatigue in an Outpatient Psychiatric Setting Elizabeth Peeples Arizona State University Archives of Psychiatric Nursing

2 EDUCATION AND COMPASSION FATIGUE 2 Abstract Aim: To determine the change in provider s compassion fatigue after implementing an education-based intervention in behavioral health. Materials and Methods: A four-part education-based intervention for compassion fatigue was implemented over the course of 16 weeks. The Professional Quality of Life instrument was used to measure compassion fatigue and compassion satisfaction. Results: Although not statistically significant, mean compassion fatigue scores decreased in the sample. Conclusion: Based on these results, further exploration into the causative factors of compassion fatigue in behavioral health are recommended. Keywords: Compassion fatigue, behavioral health, psychiatry, education

3 EDUCATION AND COMPASSION FATIGUE 3 Utilizing Education to Combat Compassion Fatigue in an Outpatient Psychiatric Setting Compassion fatigue is a challenge which can beset even the most resilient of healthcare professionals. The manifestation of compassion fatigue within an individual or organization often results in increased staff turnover, decreased workplace initiative, and poor patient outcomes (Henry, 2014). Causative factors of this phenomenon include lack of regular screening, failure to practice self care, and ongoing care of patients with high acuity diagnoses (Franza, Del Buono, & Pellegrino, 2015). Fortunately, several interventions for compassion fatigue have been identified, with education-based interventions being one of the most efficacious. Background and Significance Compassion fatigue is a state of physical or psychological distress in caregivers, the consequence of participating in an ongoing and demanding relationship with clients (Henry, 2014). Compassion fatigue can occur in any environment, but it tends to be most pronounced in acute settings such as psychiatry, oncology, and emergency medicine (Boyle, 2011). Hallmark symptoms of compassion fatigue include feelings of irritability, frustration, exhaustion, depression, anger, and avoidance. As such, compassion fatigue can greatly impede an individual s ability to effectively assess and provide care for patients. Fatigued caregivers report difficulty providing safe care, conducting thorough assessments, and therapeutically communicating with their clients (Boyle, 2011). Additionally, compassion fatigue negatively impacts the workplace by increasing the number of missed days of work, staff turnover, and by reducing initiative within the workplace (Henry, 2014). A number of benefits would be derived from the alleviation of compassion fatigue, including fewer missed workdays, decreased staff turnover, increased morale, and increased

4 EDUCATION AND COMPASSION FATIGUE 4 initiative in the workplace (Raab, 2014). In reducing compassion fatigue, providers have the energy, empathy, and patience to initiate, develop, and maintain a therapeutic relationship with their clients (Boyle, 2011). Overall, a reduction in compassion fatigue has the potential to further advance staff toward the ultimate goal of providing higher quality patient care. When analyzing compassion fatigue in a behavioral health care setting, Boyle (2011) notes that healthcare professionals working with acutely ill psychiatric patients are at great risk for developing compassion fatigue. In psychiatry, high acuity diagnoses include Cluster B personality disorders: Antisocial Personality Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and Histrionic Personality Disorder (Franza, Del Buono, & Pellegrino, 2015). These personality disorders encompass maladaptive patterns of behavior which are pervasive, inflexible, and often include overly affectual patterns of response, poor impulse control, unrealistic perceptions and expectations of others, and difficulty engaging in interpersonal relationships (Barkley, 2015). Additionally, these disorders often present with angry, aggressive, and dramatic emotional behaviors. This violence can greatly tax the emotional welfare of mental health professionals, ultimately leading to compassion fatigue (Franza, Del Buono, & Pellegrino, 2015). Providers with compassion fatigue tend to conduct less thorough assessments of their patients (Henry, 2014), are more inclined to make medication errors, and are less likely to report these errors (Reimer, 2013). Additionally, therapeutic engagement, a vital tool in mental health care, is also negatively impacted (Boyle, 2011). Mental health care professionals suffering from compassion fatigue report an inability to establish and maintain a therapeutic relationship with their patients; irritability, lack of patience, emotional exhaustion, and feelings of numbness act as a blockade in the communication between the provider and the patient (Boyle, 2011).

5 EDUCATION AND COMPASSION FATIGUE 5 A majority of interventions for compassion fatigue highlight the concept of education. Awareness and education of symptoms and causative factors of compassion fatigue (Henry, 2014), the regular implementation of mindfulness techniques and coping strategies (Raab, 2014), and continued, purposeful efforts toward self-care (Henry, 2014), are among the most efficacious interventions. When used in conjunction, these interventions can greatly reduce feelings of compassion fatigue among healthcare providers (Mathieu, 2007). The purpose of this evidencebased practice project was to determine the change in healthcare professionals compassion fatigue after implementing an education-based intervention in behavioral health. Thus, providing educational materials about compassion fatigue which consisted of identifying symptoms, causative factors, and self-care activities, as compared to current practice, may assist in decreasing the level of compassion fatigue that is experienced by mental health care professionals. The purpose of this study was to determine if an education-based intervention decreased the perceived level of compassion fatigue in staff in an outpatient psychiatric clinic. Thus, the compelling clinical question to be answered by this study was: For direct care staff working in an outpatient psychiatric setting, will providing an educational intervention to increase selfawareness of compassion fatigue consisting of identifying symptoms, causative factors, and coping strategies, as compared to current practice, decrease the level of compassion fatigue that is experienced by staff in a 16-week period? Search Strategy A search was conducted via CINAHL, Pubmed, PsycINFO, and The Cochrane Library. Index terms used in the search included compassion fatigue, nursing, psychiatric, mental health, education, and interventions. Limits included English language, adults: 18+ years, peer-

6 EDUCATION AND COMPASSION FATIGUE 6 reviewed, and publication dates from January, 2011 to January, The CINAHL search yielded 6 results, the Pubmed database yielded 8 results, the PsycINFO database yielded 10 results, and The Cochrane Library yielded 6 results. Critical Appraisal and Synthesis A literature review was conducted to ensure that all relevant evidence was identified. The evidence was then appraised via the utilization of rapid critical appraisal (Melnyk & Fineout- Overholt, 2014), and ten studies were selected for final inclusion based upon the reliability and validity of their evidence (Appendix D). Several themes were derived from the critical appraisal of these studies and their interventions. All proposed interventions were low-risk, non-invasive, and incorporated either educational training and/or promotion of self-care (Appendix B). While not every study exhibited statistical significance, all studies demonstrated a negative correlation between the education-based intervention and compassion fatigue without any adverse side effects. Each of the education-based interventions could be conducted in both an inpatient or outpatient setting, and providers in both medical and behavioral health care derived benefit from implementation of the interventions. Since evidence suggests that a decrease in compassion fatigue and its derivatives may reduce staff turnover and requested time off, an education-based intervention may provide a potential cost benefit and subsequent increase in quality of patient care. Evidence-Based Practice Model for Implementation The Rosswurm and Larrabee model served as the Evidence-Based Implementation Model for this study (Appendix C). The Rosswurm and Larrabee model consists of six formulated steps which utilize critical-thinking and decision-making skills in order to safely and effectively implement evidence-based changes (Rosswurm & Larrabee, 1999). These steps include assessing

7 EDUCATION AND COMPASSION FATIGUE 7 a need for change within the practice, linking problem interventions and outcomes, synthesizing best evidence, designing a practice change, implementing and then evaluating the change in practice, and finally integrating and maintaining the change in practice (Rosswurm & Larrabee, 1999). Theoretical Framework The Theory of Transpersonal Caring was chosen to guide the project, utilizing a framework that focuses upon the interactions between the caregiver and patient. The framework is composed of several processes which assist the caregiver in highlighting positive experiences, such as love and caring, versus negative experiences, such as death, trauma, abuse, and illness (Zehr, 2015). These processes may be extremely beneficial when utilized by caregivers experiencing compassion fatigue; when adhered to, the processes assist the caregiver in focusing upon positive experiences rather than the negative experiences that precede compassion fatigue. Implementation Plan Planning: A pre/post design was used to measure the implementation of an educationintervention on compassion fatigue using a convenience sample of 13 staff employed as direct care providers. Protection of Human Subjects: The project received Institutional Review Board approval from Arizona State University as exempt from oversight. Before collecting both the pre and post data for the project, all participants were informed about the purpose of the project, its duration, and the procedures involved. Additionally, all participants were reminded that participation was voluntarily, that they could choose to stop participating at any time, and that their identities and all data collected during the project would be kept anonymous. Participants and Setting: The project was conducted in an outpatient psychiatric clinic. All direct

8 EDUCATION AND COMPASSION FATIGUE 8 care providers at the outpatient clinic were invited to participate in the project. The clinic is located in the Southwestern United States and provides outpatient behavioral health services to children and adults. Commonly treated diagnoses at the clinic include Attention-Deficit Disorder, Major Depressive Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Schizophrenia, and various personality disorders. Inclusion and Exclusion Criteria: Inclusion criteria consisted of English-speaking full and parttime advanced practice nurses, physician assistants, behavioral therapists, and supporting staff employed at the outpatient clinic. Individuals were required to be actively providing direct patient care. All participants were 18 years or older and able to give consent. Those who did not provide direct patient care, such as administrative and non-clinical staff, were excluded from the project. Data Collection: Data was collected before and after a series of three evidence-based educational presentations on compassion fatigue. Both the pre and post survey instruments were distributed in a paper-and-pencil format. The first page of the survey was a consent page; participants were asked to read and checkmark this page before continuing with the rest of the survey. If the participant chose not to checkmark the consent page, then that participant did not complete the rest of the instrument and did not participate in the study. To avoid identifying information, the next page of the survey asked participants to create a randomized code. For post intervention data collection, the participant was asked to recreate the code in order to link the first and second survey and thus compare pre and post data. Demographics: Participants were asked five questions regarding their characteristics, including gender (male/female), profession (advanced practice nurses, physician assistants, behavioral therapists, or support staff), years of experience (in number of years), employment status (full

9 EDUCATION AND COMPASSION FATIGUE 9 time/part time), and past recognition of work (ever been recognized by employer yes/no). Practice Change Implementation: Following the conclusion of monthly, mandatory staff meetings, participants were asked to voluntarily attend a series of three education-based interventions to improve their knowledge regarding compassion fatigue and its causative factors in the field of psychiatry once a month over the course of 16 weeks. The interventions were designed specifically for the project and given as presentations. The presentations included visual displays on a large screen and an oral presentation by the primary author to the participants. Since the literature strongly suggests that compassion fatigue may be alleviated through an education based-intervention (Henry, 2014, Raab, 2014, Mathieu, 2007), the presentations consisted of information specific to compassion fatigue and its causative and alleviating factors in psychiatry. The first educational presentation conveyed information regarding the definition of compassion fatigue, its hallmark symptoms, and the overall effects of compassion fatigue on individual and workplace performance. The second presentation highlighted the potential alleviating factors of compassion fatigue, specifically focused on the necessity of psychiatric staff regularly engaging in self-care activities. These activities were explained in great detail during the presentation; including improved sleep and diet, diversified patient assignments, engagement in a hobby, pursuit of spiritual connectivity, and regular engagement in supervision and mentorship. The third presentation focused upon the potential causative factors of compassion fatigue in the field of psychiatry. Thus, the presentation conveyed information regarding Narcissistic Personality Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, and Histrionic Personality disorder. Information regarding the definitions, behavior patterns, and theory of origin were presented for each of the disorders. Furthermore, the presentation highlighted several methods for improving therapeutic

10 EDUCATION AND COMPASSION FATIGUE 10 engagement with these patients. Attendance to these educational presentations was voluntary and supported by the facility and leadership but, to participate in the post survey, participants' had to attend all three presentations. Before the start of each presentation, participants were verbally reminded that their attendance was not mandatory, and that they could leave the presentation at any time. Paid time was not offered for attending the presentations. Quality Improvement Questions: The second survey contained four quality improvement, openended questions regarding the participant's views on compassion fatigue in behavioral health (Appendix B). The purpose of these questions was to conduct quality improvement by obtaining additional data on reducing compassion fatigue in staff. Professional Quality of Life Scale (ProQOL 5): Compassion fatigue was measured using the Professional Quality of Life Scale (ProQOL version 5) (Stamm, 2010). The ProQOL is a standardized instrument consisting of 30 questions which are scored on a Likert-type scale. The scale is then further broken down into three sub-scales which measure compassion satisfaction, burnout, and secondary trauma. Burnout and secondary trauma are components of compassion fatigue, and compassion satisfaction is the satisfaction that an individual derives from their work. When the scales are scored and assessed in conjunction, information regarding the positive and negative consequences of caregiving, such as compassion fatigue, can be deduced. Statistical Analysis: The SPSS 24 statistical package program was used to assess the data. Descriptive analysis, including means, frequencies, and percentages were used to describe the sample. Spearman correlations were used to examine the relationship between the outcome variables and the demographic descriptive characteristics of the participants. The Wilcoxon Signed Ranks Test was used to assess the difference in means between the participants pre and post intervention scores in the outcome variables of burnout, secondary trauma, and compassion

11 EDUCATION AND COMPASSION FATIGUE 11 satisfaction. The level of significance was set at p < Results Thirty-two out of a potential eighty-six direct care providers initially participated in the pre intervention data collection with 13 providers completing the post-intervention. The recidivism rate was 40.6%. The majority of the 13 participants were female (76.9%), employed full-time (92.3%), working as behavioral therapists (46.2%), and had not received any past awards or recognition related to their work performance (69.2%). Participants had either 1-4 years of work experience (38.5%), or 5-10 years (38.5%) (Figure A1). Per the ProQOL selfscoring measure, this population also exhibited lower than average mean scores for burnout and secondary traumatic stress; the mean burnout score was (SD = 4.50), and the mean secondary traumatic stress score was (SD = 3.38). Per the ProQOL self-scoring measure, this population also exhibited average mean scores for compassion satisfaction; the mean compassion satisfaction score was (SD = 3.90) (Figure A2). Nonparametric analysis using a Wilcoxon Signed Ranks Test determined that no statistically significant relationship existed between the pre and post intervention scores; burnout (p=.205, p< 0.05), secondary traumatic stress (p=.556, p<0.05), and compassion satisfaction (p=.234, p<0.05). Each of the 13 participants completed the four quality improvement, open-ended questions regarding the participant's views on compassion fatigue in behavioral health. Common themes identified within the responses included subjective feelings of compassion fatigue related to high patient volume and high workload (Appendix B). Discussion The purpose of this EBP project was to evaluate whether the implementation of an

12 EDUCATION AND COMPASSION FATIGUE 12 education based intervention reduced compassion fatigue in behavioral health providers. Although staff had anecdotally reported strong feelings of compassion fatigue before the start of the study, study results indicated the sample demonstrated average levels of burnout, secondary traumatic stress, and compassion satisfaction according to published cutoff levels by the ProQOL manual. However, the scores found in this sample align with previously published burnout, secondary trauma, and compassion satisfaction scores for nurses in the literature (Flarity et. al, 2016; Hunsaker, Chen, Maughan, Heaston, 2015; Kelly, Runge, Spencer, 2015). One explanation may be the established normative values are based on a sample of all professions that submit scores for inclusion in the ProQOL database. Additionally, this discrepancy in subjective versus objective data may be explained by the fact that negative perceptions of the workplace may possibly be correlated with subjective feelings of burnout (Thompson, Amatea, Thompson, 2014). Indeed, participants negative perceptions of the workplace were captured via the quality improvement questions administered during the post ProQOL. According to themes identified in the responses (Appendix B), participants expressed dissatisfaction with the high number of patients that must be seen each day, and the short amount of time allotted to see these patients. In a previous study conducted by Yada et al. (2014), psychiatric nurses were found to have greater than average workloads when compared to other nursing fields. This is because behavioral health does not solely focus upon mental health. Rather, psychiatric nurses are required to care for both the mental and physical needs of patients. When coupled with severe time restraints and high volume, these increased care demands can result in increased quantitative overloads of physical and mental workloads which, in turn, can lead to an overall increase in subjective feelings of stress and exhaustion (Yada, Lu, Omori, Abe, Matsuo, Ishida, & Katoh, 2014). Although participants burnout levels are not yet significant, evidence suggests

13 EDUCATION AND COMPASSION FATIGUE 13 that compassion fatigue may develop if the negative perceptions of the workplace persist. Another important finding deduced includes participants reporting causative factors which differed from those identified in the literature. According to the literature, patients exhibiting impulsive, violent, and dramatic behaviors (such as individuals with cluster B personality disorders), are one of the greatest causative factors of compassion fatigue in behavioral health (Boyle, 2011). However, according to the themes identified in the responses to the quality improvement questions administered during the post ProQOL (Appendix B), participants did not identify the cluster B personality disorders as a causative factor of compassion fatigue. Rather, most participants reported that they were more negatively affected by the high number of patients which they were required to see each day, and the substantial workload which accompanies each of these patients. Indeed, the literature suggests that large caseloads coupled with lack of leadership support can increase workplace stress and thus potentially lead to burnout and increased compassion fatigue (Flarity, Rhodes, & Reckardl, 2016). In behavioral health, literature suggests that perceptions of workload have a significant influence upon the provider s emotional exhaustion and tendencies toward depersonalization, and thus high workloads may indeed increase the likelihood of compassion fatigue development in behavioral health professionals (Bogaert, P., Clarke, S., Wouters, K., Franck, E., Willems, R., & Mondelaers, M, 2013). Thus, further study regarding the causative factors of compassion fatigue in behavioral health may be warranted. Although evidence suggests that education-based interventions are one of the most efficacious methods for alleviating compassion fatigue, the implemented EBP project did not result in a statistically significant decrease in compassion fatigue. However, although not statistically significant, levels of burnout and secondary traumatic stress decreased after the

14 EDUCATION AND COMPASSION FATIGUE 14 education intervention, demonstrating positive trends for improvement possibly subsequent to the implementation of the education-based intervention (Figure A2).The goal of the education based intervention incorporated the current evidence regarding the symptoms and causative factors of compassion fatigue (Henry, 2014), and the importance of continued, purposeful efforts toward self-care (Henry, 2014), to result in reduced feelings of compassion fatigue among healthcare providers. Strengths and Limitations of the EBP Project Several possible limitations may explain the outcome. First, data may have been skewed by the unequal number of participants in the pre and post interventions; although 32 staff members initially participated, the project consisted of 13 pre and post paired compassion fatigue assessments for analysis. The small sample size may have skewed the results in that those who participated may have differed from those who did not. Secondly, the education-based intervention may require revision. Data analysis demonstrated a patterned decrease in burnout and secondary traumatic stress and an increase in compassion satisfaction which suggests that an education-based intervention may indeed be an efficacious means of alleviating compassion fatigue in behavioral health. However, the intervention may need to be implemented in a shorter time span rather than over 16 weeks. Additionally, the education regarding causative factors of compassion fatigue may need to be revised to include high workload and volume rather than Cluster B personality disorders. Despite its limitations, it should be noted that the project also exhibited several strengths. As a whole, the project was evidence-based and utilized an intervention supported by the literature. A validated tool, the ProQOL, was used as the instrument of measurement, and the participants of the project were interprofessional and thus created a well-rounded and diverse sample group.

15 EDUCATION AND COMPASSION FATIGUE 15 Future Implications and Conclusion Although this study did not find a statistically significant decrease in compassion fatigue after implementing the evidence-based intervention, the findings contribute to the current body of knowledge regarding compassion fatigue in behavioral health, and advanced quantitative studies should be conducted to further determine the causative factors of compassion fatigue in psychiatry. Additionally, this information should then be incorporated into an education-based intervention and implemented within a psychiatric setting determined to have higher than average burnout and secondary traumatic stress scores. This will allow behavioral health professionals to self-identify, deduce the cause of, and independently engage in activities which will inhibit the development of compassion fatigue. In turn, these professionals will experience improved energy, empathy, morale, and therapeutic communication. Overall, knowledge of compassion fatigue in behavioral health will result in improved quality of patient care. In conclusion, future studies will provide additional insight into using education-based interventions to combat compassion fatigue in behavioral health. Conflict of interests None.

16 EDUCATION AND COMPASSION FATIGUE 16 References American Community Survey Highlight Report. (2013). Men in nursing occupations. U.S. Census Bureau. Retrieved from Barkley & Associates. (2015). Psychiatric Mental Health Nurse Practitioner. West Hollywood, CA: Barkley& Associates. Bogaert, P., Clarke, S., Wouters, K., Franck, E., Riet, W., & Mondelaers, M. (2013). Impacts of unit-level nurse practice environment, workload and burnout on nurse-reported outcomes in psychiatric hospitals: A multilevel modeling approach. International Journal of Nursing Studies, 50(3), Boyle, D. (2011). Countering compassion fatigue: a requisite nursing agenda. Online Journal of Issues in Nursing, 16(1), 1-1. Retrieved from Flarity, K., Rhodes, W., & Reckardl, P. (2016). Intervening to improve compassion fatigue

17 EDUCATION AND COMPASSION FATIGUE 17 resiliency in nurse residents. Journal of Nursing Education and Practice, 6(12), doi: /jnep.v6n12p99 Franza, F., Del Buono, G., & Pellegrino, F. (2015). Psychiatric caregiver stress: clinical implications of compassion fatigue. Psychiatria Danubina, Retrieved from Henry, B. (2014). Nursing burnout interventions: what is being done? Clinical Journal of Onocology Nursing, 18(2), Retrieved from &id=pmid: Hunsaker, S., Chen, H., Maughan, D., & Heaston, S. (2015). Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses. Journal of Nursing Scholarship, 47(2), doi: /jnu Mathieu, F. (2007). Running on empty: compassion fatigue in health professionals. Rehab & Community Care Medicine, 1-6. Retrieved from Melnyk, B.M., & Fineout-Overholt, E. (2014). Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice (3 rd ed.). Lippincott, Williams & Wilkins. ISBN-13: ISBN-10: Raab, K. (2014). Mindfulness, self-compassion, and empathy among health care professionals: a review of the literature. Journal of Health Care Chaplaincy, 20(3), Retrieved from Reimer, N Creating moments that matter: strategies to combat compassion fatigue,

18 EDUCATION AND COMPASSION FATIGUE 18 Clinical Journal of Oncology Nursing, 17(6), Retrieved from &id=pmid: Rosswurm, M. & Larrabee, J. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), doi: /j tb Smart, D., English, A., James, J., Wilson, M., Daratha, K. B., Childers, B., & Magera, C. (2014). Compassion fatigue and satisfaction: A cross sectional survey among US healthcare workers. Nursing & Health Sciences, 16(1), doi: /nhs Stamm, The concise ProQOL manual. Retrieved from Tarantino, B., Earley, M., Audia, D., D'Adamo, C., & Berman, B. (2013). Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare professionals. Explore, 9(1), doi: /j.explore Thompson, I. A., Amatea, E. S., & Thompson, E. S. (2014). Personal and contextual predictors of mental health counselors' compassion fatigue and burnout. Journal Of Mental Health Counseling, 36(1), Retrieved from &site=ehost-live Yada, H., Lu, X., Omori, H., Abe, H., Matsuo, H., Ishida, Y., & Katoh, T. (2014). Exploratory study of factors influencing job-related stress in Japanese psychiatric nurses. Nursing Research and Practice, 2015(2015), 1-7. doi: /2015/ Zehr, Kathryn. (2015). The effect of education on compassion fatigue as experienced by staff nurses. Valparaiso University. Retrieved from

19 EDUCATION AND COMPASSION FATIGUE 19 Zeidner, M., Hadar, D., Matthews, G., & Roberts, R. D. (2013). Personal factors related to compassion fatigue in health professionals. Anxiety, Stress, and Coping, 26(6), 595. doi: / Appendix A Table 1. Demographic Characteristics (n: 13). Frequency Percent Gender Male Female Total Provider Advanced Practice 3 Nurse Therapist Other Total Employment Full Time Part Time Total Years of Experience Total Past Award/ Received Recognition Recognition* No Recognition Total *Measured as have you ever received an award/recognition for your work (such as Employee of the Month, a DAISY nomination, etc)? Table 2. The Descriptive Statistics of the Pre and Post

20 EDUCATION AND COMPASSION FATIGUE 20 ProQOL 5 Scoring Measures N Mean Std. Z Asymp. Deviation Sig. (2 -tailed) Burnout Pre-Intervention Post-Intervention Secondary Traumatic Stress Compassion Satisfaction Pre-Intervention Post-Intervention Pre-Intervention Post-Intervention *Note. Significance at the p<0.05 level. Table 3. The pre and post mean scores of BO, STS, and CS per provider type. Provider Burnout Secondary Trauma Compassion Satisfaction Pre Mean Post Mean Pre Mean Post Mean Pre Mean Post Mean Advanced Practice Nurse (n=3) Behavioral Therapist (n=6) Other Direct Care Provider (n=4)

21 EDUCATION AND COMPASSION FATIGUE 21 Appendix B Table 1 Themes identified within the QI questions. What is one thing you learned about compassion fatigue? Theme 1 Theme 2 Theme 3 Increased awareness of the signs and symptoms of compassion fatigue. The risks of compassion fatigue, including physical, emotional, and mental exhaustion. Managing, understanding, and relieving compassion fatigue through self-care. With regard to working in behavioral health, what do you believe increases your feelings of compassion fatigue? Increased workload/larger caseloads increase the risk of developing compassion fatigue. Lack of support from management increases the risk of developing compassion fatigue. What can you do to reduce your feelings of compassion fatigue? Being aware of personal health and recognizing signs of compassion fatigue. Engage in activities to decrease stress and increase well-being, and engage in therapeutic communication with friends, family, and coworkers.

22 SIGNIFICANCE OF COMPASSION FATIGUE 22 Appendix C 1. Assess need for change in practice 2. Link problem intervention and outcomes 3. Synthesize best evidence 4. Design practice change 5. Implement and evaluate change in practice 6. Integrate and maintain change in practice Internal evidence - project site reported subjective feelings of CF External evidence - psychiatric providers are at risk for developing CF (Boyle, 2011) CF can increase staff turnover, decrease workplace initiative, and result in poor patient outcomes (Henry, 2014) Awareness and education of symptoms (Henry, 2014) Continued, purposeful efforts toward self-care (Henry, 2014) Education-based interventions which stress self-care and self-awareness may reduce BO and STS, and increase CS (Mathieu, 2007) Reduced CF may result in increased patient safety and quality of care (Boyle, 2011) Search conducted via CINAHL, Pubmed, PsycINFO, and The Cochrane Library Evidence was appraised via rapid critical appraisal (Melnyk & Fineout- Overholt, 2014) Ten studies were selected for final inclusion All proposed interventions were low-risk, noninvasive, and incorporated either educational training and/or promotion of self-care Series of evidencebased presentations designed to decrease compassion fatigue in outpatient behavioral health providers CF measured using validated ProQOL instrument Rigorous pre/post design used to measure implementation of intervention on CF Average burnout and secondary trauma scores decreased after the education intervention, however, not a statistically significant decrease Average compassion satisfaction scores increased after the education based intervention, although not a statistically significant increase Common themes identified in QI questions included subjective feelings of CF related to high patient volume and high workload Thorough synthesis of literature contributes to the knowledge regarding CF in behavioral health Advanced quantitative studies should be conducted to further determine the causative factors of CF in behavioral health Knowledge of CF in behavioral health may result in improved quality of patient care

23 SIGNIFICANCE OF COMPASSION FATIGUE 23 Table 1 Appendix D Evaluation Table: Interventions for Compassion Fatigue in Health Care Providers Citation Smart, D. (2014). Compassion fatigue and satisfaction: A crosssectional survey among US healthcare workers. Country: United States Funding: NA Stakeholders: NA Bias: None noted Conceptua l Framewor k Stress Process Framework Design/ Method Design: Cross- Sectional Study Purpose: To investigate compassion satisfaction and compassion fatigue levels in a community hospital in the United States. Sample/ Setting N= 139 SS=1 IP=1 OP=0 Role Physicians= 2% Direct Care RNs= 54% CNA= 44% Race Caucasian= 96% Major Variables & Definitions IV1: CS IV2: ST DV1: BO Measurem ent ProQOL-V Data Analysis ANOVA SPSS version 17.0) Findings Negative correlation between CS and BO r = , P < Negative correlation between CS and ST r = , P < Positive correlation between ST and BO Level/Quality of Evidence; Decision for practice/ application to practice Level of Evidence: Level III Strengths: Lowrisk, noninvasive intervention, measurement and data analysis tools are reliable and valid. Weaknesses: Small sample group, little variability in demographics of sample group, only 1 SS. APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale

24 SIGNIFICANCE OF COMPASSION FATIGUE 24 Other=4% r = 0.580, P < Conclusions: If CS is >, BO can be decreased. CS can be improved via stress-reduction practices and selfcare. Citation Tarantino, B (2013). Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare. Country: United States Funding: NR Stakeholders:NA Bias: PSS conducted by staff members directly involved in self-care Conceptua l Framewor k Stress Process Framework Design/ Method Design: Cross- Sectional Study Purpose: To deduce if an integrative self-care program can decrease stress and thus improve functioning and Sample/ Setting N= 82 SS=1 IP=0 OP=1 Role RNs and APNs = 90% Social workers and therapists = 10%. Major Variables & Definitions IV1: Self-care program DV1: S Measurem ent Perceived Stress Scale (PSS) Data Analysis Analysis of Variance in PSS Findings PI S = 16.9 S after 8 weeks of interventio n= 11.7 Level/Quality of Evidence; Decision for practice/ application to practice Level of Evidence: Level III APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale PoI S = 14.4 Strengths: Lowrisk, noninvasive intervention, measurement tool is reliable and valid, post-intervention assessment included a 12 month followup. Weaknesses: Selection bias due to participants being self-selected.

25 SIGNIFICANCE OF COMPASSION FATIGUE 25 training, thus incurring possible sampling bias. wellbeing for nurses and other healthcare providers. Randomized and controlled design not utilized. Possible sampling bias. Conclusions: Healthcare workers who engage in selfcare activities may experience decreased stress. Citation Zeidner, M. (2013). Personal factors related to compassion fatigue in health professionals. Country: Israel Conceptua l Framewor k General Adaption Syndrome Theory Design/ Method Design: Cross- Sectional Study Purpose: To examine the role of some Sample/ Setting N=182 SS= 10 OP= 3 IP=7 Setting Seven major hospitals Major Variables & Definitions IV1= EI IV2= EM DVI = CF Measurem ent Schutte self-report inventory (SSRI) Emotionmanageme nt subscale Data Analysis Hot Deck imputation procedure Findings EI and EM are inversely related to CF. EI: B=-.19, t=-2.78, p<.01 Level/Quality of Evidence; Decision for practice/ application to practice Level of Evidence: Level III Strengths: Low-risk, noninvasive intervention, multiple measurement tools, multiple SS, varied APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale

26 SIGNIFICANCE OF COMPASSION FATIGUE 26 Funding: NA Stakeholders: NA Bias: None noted personal and professional factors in compassion fatigue among health-care professional s. and six private clinics in Northern and Central Israel. Role Mental Health Providers: 49% Medical Health Providers: 51% of the MayerSalo veycaruso emotional intelligence test (MSCEIT) Coping inventory for stressful situations situation specific coping (CISS- SSC) Mood subscales of the Dundee stress state questionnai re EM: B = -.17, t= , p<.01 demographic of N. Weaknesses: Time limitation, study was not designed to address the dynamic relationship between negative emotional states, S, and CF. Conclusions: Increased EI and EM may act as protective factors against CF. EI and EM can be increased via utilizing effective and healthy coping strategies. ProQOL- III APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale

27 SIGNIFICANCE OF COMPASSION FATIGUE 27 Citation Zehr, Kathryn. (2015). The effect of education on compassion fatigue as experienced by staff nurses. Country: United States Funding: NR Stakeholders: Unit director and CNO of Hospital X Bias: None noted Conceptua l Framewor k The Theory of Transperso nal Caring Design/ Method Design: Case-control study Purpose: Purpose of study was to increase awareness about CF risks, symptoms, and coping mechanisms through educational training for registered nurses in an effort to decrease levels of CF. Sample/ Setting N= 33 SS =1 IP=1 OP=0 MA = Mid twenties late fifties F = 100% All participants were RNs who worked on a medicalsurgical unit at Hospital X, a level II trauma center in northern Indiana. Major Variables & Definitions IV1= Educational Training DV1 = Compassion Fatigue Measurem ent Data Analysis Findings ProQOL-V ANOVA AS for ST =20.7 AS for CS =39.1 PI MS=39.1 PoI MS = month PoI MS = month PoI MS =38.4 P value for CS = P value for ST = Level/Quality of Evidence; Decision for practice/ application to practice Level of Evidence: Level III Strengths: Low-risk, noninvasive intervention, measurement tool credited with being reliable and valid, PoI analysis was conducted immediately after intervention and at 1 and 3 month PoI. Weaknesses: Variability in the educational sessions, sessions were only 30 minutes in length, small N. Conclusions: Educational training is best practice to APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale

28 SIGNIFICANCE OF COMPASSION FATIGUE 28 decrease levels of CF among staff nurses. Citation Ruotsalainen J., Verbeek J., Mariné Albert., & Serra C. (2015). Preventing occupational stress in healthcare workers. Country: NR Funding: NR Bias: None noted Conceptua l Framewor k Physiologic Theory Design/ Method SR based on Cochrane review criteria. Purpose= To evaluate the effectiveness of work and person directed intervention s compared to no intervention or alternative intervention s in preventing Sample/ Setting n = 58 n, RCT = 54 n, non-rct = 4 N =7, 188 MP = 100% Inclusion Criteria = RCTs of intervention s aimed at preventing psychologic al stress in healthcare workers. For organization al intervention Major Variables & Definitions IV1: PR (Massage) IV2: MR (Meditation) IV3: CBT with Relaxation IV4: CBT without Relaxation IV5: OC DV1: Stress Measurem ent GRADE System Data Analysis Standardize d Mean Differences (SMDs) Findings PR: SMD , 95% CI to MR: SMD -0.50, 95% CI to 0.15 OC: SMD -0.55, 95% CI to CBT w/ and w/out Relaxation: SMD -0.27, Level/Quality of Evidence; Decision for practice/ application to practice Level of Evidence: Level I Strengths: Low risk and noninvasive intervention, high level of evidence, majority of studies reviewed were RCTs, large N. Weaknesses: More RCTs are needed with at least 120 participants that compare the intervention to a placebo-like intervention. APN-advanced practice nurse; AS-average score; BHT-behavioral health technician; BO-burnout; BPRS-brief psychiatric rating scale; CBIcaregiver burden inventory; CF-compassion fatigue ; CFSTH- compassion fatigue self test for helpers; CFSR- compassion fatigue scale revised; CIconfidence interval; CS-compassion satisfaction; DV-dependent variable ;EB- evidence based; EI- emotional intelligence; EM emotional management; ET-educational training; F-female; IES-R- impact event scale-revised; IP-inpatient; IV- independent variable; LR-literature review; M-male; MBI-maslach burnout inventory; MI-mindfulness; MA-mean average; MP-medical profession; MR mental relaxation; MS-mean score; n-number of studies; N- number of participants; NJSS- nursing job satisfaction scale; non-rct- non-randomized controlled trials; NR-none reported; OC-organizational changes; OP-outpatient; PI-pre-intervention; PoI-post-intervention; PR-physical relaxation; ProQOL-professional quality of life scale; PSS-perceived stress scale; QE-quasi-experimental; RCT-randomized controlled trial; RN-registered nurse; RR-response rate; S-stress; SC-self care; SCFs-short compassion fatigue scale; SR-systematic review; SS-setting site; ST-secondary stress; STSS-secondary traumatic stress scale